The removal of one or more hemorrhoids can lead to several coding dilemmas for general surgery coders. First, it may be difficult to choose from several specific hemorrhoid removal codes. Second, if more than one hemorrhoid is removed, or if more than one procedure is performed, the coder must know which procedures include multiple removals and which are bundled. Third, if the surgeon performs a significant, separately identifiable evaluation and management (E/M) service, or a scope of some kind or both in addition to the removal, the coder must decide which procedures can be billed seperately.

Hemorrhoids are veins in the anus and/or rectum that have dilated, resulting in an increased size (varicosity). If the hemorrhoid originates above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge), it is classified as an internal hemorrhoid. Internal hemorrhoids are treatable with over-the-counter medications, but if persistent they may require surgical intervention. By far the most common hemorrhoid removal procedure is rubber band ligature (46221, hemorrhoidectomy, by simple ligature [e.g., rubber band]) notes M. Trayser Dunaway, MD, a general surgeon in Camden, S.C.

CPT also describes other means, aside from excision, of removing internal hemorrhoids. Code 46500 involves sclerotherapy the injection of sclerosing solution into the submucosa of the rectal wall under the hemorrhoid columns. Other methods of destroying hemorrhoids, which include using electrical current or infrared radiation, are coded 46934 (destruction of hemorrhoids, any method; internal). Each of these procedures is performed far less frequently than banding.

Note: Code 46935 describes destruction of external hemorrhoids by any method; 46936 describes destruction of internal and external hemorrhoids by any method. Like 46934, these codes are rarely used.

External hemorrhoids, unlike internal hemorrhoids, originate below the dentate line. Patients may be unaware they have an external hemorrhoid unless and until they develop a blood clot (thrombosed external hemorrhoid). When this occurs, Dunaway says, the surgeon has three options: (1) do nothing, and eventually the thrombosed hemorrhoid will become a skin tag; (2) perform incision and drainage (I&D) to remove the clot only; or (3) excise the vessel and the clot simultaneously.

The second and third options involve immediate procedures. For I&D, code 46083 (incision of thrombosed hemorrhoid, external); if the clot and hemorrhoid are excised, use 46320 (enucleation or excision of external thrombotic hemorrhoid). The first option, however, may also involve a procedure at a later date if the patient and surgeon determine that the skin tags (which contain no blood vessels) need to be removed. In that case, 46220 (papillectomy or excision of single tag, anus [separate [...]